Health policy and clinical practice/review article
Frequent Users of Emergency Departments: The Myths, the Data, and the Policy Implications

https://doi.org/10.1016/j.annemergmed.2010.01.032Get rights and content

Study objective

Frequent emergency department (ED) users have been the targets of health care reform proposals and hospital crowding interventions, but it is not clear that common assumptions about this group are supported by data. We review the literature pertaining to frequent ED users, their demographics, acuity of illness, and patterns of health care utilization. We seek to inform development of policies directed at frequent ED use and to highlight potential related challenges.

Methods

A systematic review of the literature on frequent ED users was performed.

Results

Frequent users comprise 4.5% to 8% of all ED patients but account for 21% to 28% of all visits. Most frequent ED users are white and insured; public insurance is overrepresented. Age is bimodal, with peaks in the group aged 25 to 44 years and older than 65 years. On average, these patients have higher acuity complaints and are at greater risk for hospitalization than occasional ED users. However, the opposite may be true of the highest-frequency ED users. Frequent users are also heavy users of other parts of the health care system. Only a minority of frequent ED users remain in this group long term. Complaints vary with age, location, and usage patterns.

Conclusion

Frequent ED users are a heterogeneous group along many dimensions and defy popular assumptions. The subgroups have not yet been sufficiently defined to allow clearly directed policy design, and many frequent users present with true medical needs, which may explain why existing attempts to address the phenomena have had mixed success at best.

Introduction

Because hospital emergency departments (EDs) experienced a dramatic 36% increase in patient volume from 1996 to 2006,1 increasing interest has focused on a group of individuals who contribute a disproportionate number of visits. This interest has been amplified during the recent health care reform debate in the United States, with politicians from both sides of the aisle and the lay press seizing on reducing ED use as a possible cost-saving measure.2, 3 Patients with frequent ED visits are often portrayed as unscrupulous, uninsured, and unnecessarily clogging EDs by presenting with primary care complaints better treated elsewhere.4, 5, 6

Widely held assumptions about the patient population who frequently visits EDs, and their reasons for visiting, have not been, for the most part, supported by research on the topic. Although the practicing provider may regularly encounter the stereotypical frequent ED user, this snapshot may not accurately reflect the true nature of frequent ED use and may be a distraction in the development of effective interventions to improve access to health care and, where appropriate, curb heavy ED use.

This review of literature pertaining to frequent ED users aims to summarize what is known about frequent users' demographics, degree and types of illness, access to other medical care, and utilization patterns. Our goal is to inform policy development directed at frequent ED users and at improvement of access to health care in general and to highlight potential challenges.

Section snippets

Materials and Methods

A systematic review of the literature was performed, using previously described methods7 as applicable to this topic. The review was designed to capture studies describing the population of patients who demonstrate frequent use of EDs in the United States. “Frequent use” was defined by each study as no standard definition exists.

The following inclusion criteria were used:

  • 1

    Population/Setting: Studies of adult and pediatric patients presenting frequently to EDs in the United States were included.

  • 2

Results

The structured MEDLINE search yielded 25 unique results meeting criteria described above. Table 1 shows the number of relevant results for each term that produced studies meeting inclusion/exclusion criteria. Fourteen studies reviewed represented data from single sites,8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 whereas 11 studies used multisite or population-level data (see Table 2).22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32 Overall, the EDs studied are predominantly university

Discussion

First, the data from these studies challenge the common assumption that frequent ED use is a problem of uninsured, ethnic minority patients inappropriately seeking basic primary care in the ED. Although black patients are at higher risk of being frequent users, the majority of these visits are attributable to white patients. Most frequent users are either publicly or privately insured, and, perhaps surprising to some, frequent users also have concurrently high utilization of primary care and

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    Supervising editor: Donald M. Yealy, MD

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement.

    Publication date: Available online March 26, 2010.

    Earn CME Credit: Continuing Medical Education is available for this article at: www.ACEP-EMedHome.com.

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